ASSESSING THE NECK Flashcards
(10 cards)
A nurse is assessing the neck of a client. Which of the following findings should the nurse report to the healthcare provider?
A. Symmetrical neck muscles
B. Midline trachea
C. Palpable, tender cervical lymph nodes
D. Smooth, non-palpable thyroid
C. Palpable, tender cervical lymph nodes
Rationale: Tender cervical lymph nodes may indicate infection or malignancy and should be reported.
During a routine assessment, the nurse palpates the thyroid gland from behind the patient. Which of the following is a normal finding?
A. Enlarged lobes with nodules
B. Firm and fixed thyroid gland
C. Slightly palpable, non-tender lobes
D. Audible bruit over the thyroid
C. Slightly palpable, non-tender lobes
Rationale: A normal thyroid may be slightly palpable and should be smooth and non-tender.
A nurse notes that the trachea is deviated to the left. What is the nurse’s priority action?
A. Document the finding and continue
B. Assess for signs of respiratory distress
C. Reposition the client
D. Ask the client to cough and recheck
B. Assess for signs of respiratory distress
Rationale: Tracheal deviation may signal a medical emergency (e.g., tension pneumothorax); assess airway and breathing first.
A client reports neck stiffness and headache. What is the nurse’s next appropriate action?
A. Palpate for lymph nodes
B. Check for jugular vein distention
C. Assess for Brudzinski’s sign
D. Perform range-of-motion exercises
C. Assess for Brudzinski’s sign
Rationale: Neck stiffness and headache could indicate meningitis; Brudzinski’s sign tests for meningeal irritation.
While palpating lymph nodes in the neck, the nurse finds small, mobile, and non-tender nodes. What is the appropriate nursing action?
A. Notify the healthcare provider
B. Schedule the client for a biopsy
C. Document the findings as normal
D. Apply a warm compress to the area
C. Document the findings as normal
Rationale: Small, mobile, non-tender nodes are generally considered a normal finding.
Which technique should the nurse use to assess the carotid arteries during a neck exam?
A. Palpate both carotid arteries simultaneously
B. Use the bell of the stethoscope to auscultate
C. Press firmly on one side of the trachea
D. Use the diaphragm to listen for bruits
B. Use the bell of the stethoscope to auscultate
Rationale: The bell of the stethoscope is best for auscultating low-pitched sounds like carotid bruits.
A nurse is assessing an older adult’s neck and finds limited range of motion. What is the most appropriate nursing response?
A. Assume the client has arthritis
B. Document the finding as normal for aging
C. Instruct the client to perform neck exercises
D. Notify the healthcare provider immediately
B. Document the finding as normal for aging
Rationale: Limited neck ROM can be a normal age-related change due to degenerative joint changes.
Which assessment finding of the thyroid gland would be most concerning?
A. Soft texture
B. Non-palpable lobes
C. Nodule that is firm and fixed
D. Symmetrical lobes on palpation
C. Nodule that is firm and fixed
Rationale: A firm, fixed nodule may indicate malignancy and warrants further evaluation.
The nurse auscultates a bruit over the thyroid. What does this indicate?
A. Normal finding in older adults
B. Hypothyroidism
C. Increased vascularity, possibly hyperthyroidism
D. Blocked carotid artery
C. Increased vascularity, possibly hyperthyroidism
Rationale: A bruit indicates increased blood flow, often seen in hyperthyroidism.
When assessing lymph nodes, which characteristic would be most concerning for malignancy?
A. Bilateral, soft, and movable
B. Small and tender
C. Hard, non-tender, and fixed
D. Enlarged during an upper respiratory infection
C. Hard, non-tender, and fixed
Rationale: Hard, fixed lymph nodes are concerning for malignancy and require further investigation.
